Healthcare Provider Details

I. General information

NPI: 1760733539
Provider Name (Legal Business Name): WINGS OF EAGLES BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PINE BLUFF RD
CHATHAM LA
71226-7904
US

IV. Provider business mailing address

201 PINE BLUFF RD
CHATHAM LA
71226-7904
US

V. Phone/Fax

Practice location:
  • Phone: 318-737-2566
  • Fax: 318-933-7385
Mailing address:
  • Phone: 318-737-2566
  • Fax: 318-933-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3601
License Number StateLA

VIII. Authorized Official

Name: MR. TERRY DRISKILL
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential: LPC
Phone: 318-737-2566